Barbara Ogur

Longitudinal Integrated Clerkships for Medical Students: An Innovation Adopted by Medical Schools in Australia, Canada, South Africa, and the United States

Purpose Integrated clinical clerkships represent a relatively new and innovative approach to medical education that uses continuity as an organizing principle, thus increasing patient-centeredness and learner-centeredness. Medical schools are offering longitudinal integrated clinical clerkships in increasing numbers. This report collates the experiences of medical schools that use longitudinal integrated clerkships for medical student education in order to establish a clearer characterization of these experiences and summarize outcome data, when possible. Method The authors sent an e-mail survey with open text responses to 17 medical schools with known longitudinal integrated clerkships. Results Sixteen schools in four countries on three continents responded to the survey. Fifteen institutions have active longitudinal integrated clerkships in place. Two programs began before 1995, but the others are newer. More than 2,700 students completed longitudinal integrated clerkships in these schools. The median clerkship length is 40 weeks, and in 15 of the schools, the core clinical content was in medicine, surgery, pediatrics, and obstetrics-gynecology. Eleven schools reported supportive student responses to the programs. No differences were noted in nationally normed exam scores between program participants and those in the traditional clerkships. Limited outcomes data suggest that students who participate in these programs are more likely to enter primary care careers. Conclusions This study documents the increasing use of longitudinal integrated clerkships and provides initial insights for institutions that may wish to develop similar clinical programs. Further study will be needed to assess the long-term impact of these programs on medical education and workforce initiatives.

Educational Outcomes of the Harvard Medical School-Cambridge Integrated Clerkship: A Way Forward for Medical Education

Purpose The authors report data from the Harvard Medical School–Cambridge Integrated Clerkship (CIC), a model of medical education in which students’ entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships. Method The authors compared 27 students completing the first three years of the CIC (2004–2007) with 45 students completing clerkships at other Harvard teaching hospitals during the same period. At baseline, no significant between-group differences existed (Medical College Admission Test and Step 1 scores, second-year objective structured clinical examination [OSCE] performance, attitudes toward patient-centered care, and plans for future practice) in any year. The authors compared students’ National Board of Medical Examiners Subject and Step 2 Clinical Knowledge scores, OSCE performance, perceptions of the learning environment, and attitudes toward patient-centeredness. Results CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness. Conclusions CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.

Learning Through Longitudinal Patient Care—narratives From the Harvard Medical School–cambridge Integrated Clerkship

Purpose Most medical schools value and seek to create opportunities for students to learn through experiences in the longitudinal care of patients. A number of innovative programs have made longitudinal care the central experiential component of principal clinical year education. The authors sought to identify ways in which learning through the longitudinal care of patients in an innovative longitudinal integrated clerkship contributes to the education of students in their principal clinical year. Method The authors reviewed 16 narratives written by 14 of the 38 students from the first four years of the Harvard Medical School–Cambridge Integrated Clerkship, 2004–2007, to identify important aspects of learning from longitudinal care. Results Students reported that the clerkship structure created a dynamic learning environment that helped them to more broadly learn about their patients’ diseases and experiences of illness. Students described feeling deeply connected to “their” patients, which transformed their roles and inspired their reflections. With more thorough knowledge of their patients over time, they felt they made important contributions to their patients’ care, not only in providing emotional support but also in bridging gaps in the delivery of services and in motivating deeper exploration into relevant medical and social issues. Students reported that their connections with patients over time inspired a sense of idealism and advocacy. Conclusions Organizing learning in the principal clinical year around longitudinal patient care seems to offer significant advantages for learning and professional development.

The role of role: learning in longitudinal integrated and traditional block clerkships

Medical Education 2012: 46:698–710

More is better: students describe successful and unsuccessful experiences with teachers differently in brief and longitudinal relationships.

Purpose Clerkship experiences that structure student–teacher continuity may promote learning differently than brief student–teacher relationships. The authors compared students’ successful and unsuccessful teaching experiences in brief and longitudinal relationships. Method A multicenter, qualitative interview study was conducted in 2009–2010 of students in two clerkship models that provide different durations of student–teacher relationships. Each student described a successful and unsuccessful teaching relationship early and late in the core clerkship year. Questions explored teachers’ strategies and behaviors and students’ efforts to improve unsuccessful relationships. Interview transcripts were coded to identify major themes. Results Fifty-four students completed interviews. Students in brief relationships struggled to be known; students in longitudinal relationships felt respected as learners and partners. Teaching strategies differed in the two relationship durations. Questioning about factual knowledge was common in brief relationships; collaborative knowledge sharing and application to patients occurred in longitudinal relationships. Hierarchy characterized brief relationships. Longitudinal students experienced evolving expectations in response to their growing skills and contributions. Only students in longitudinal relationships described successfully intervening to improve unsuccessful relationships; students in brief relationships felt powerless. Conclusions Clerkship students in brief relationships learn to adapt to teachers’ preferences and questioning to facilitate their participation and knowledge acquisition; longitudinal students experience collaborative interactions focused on their development as care providers. In longitudinal relationships, students gain confidence to influence their own learning and modify circumstances to meet their learning needs. These findings suggest that medical students’ clinical experiences may be enhanced by deliberately structuring longitudinal attachments to supervisors.

Into the future: patient-centredness endures in longitudinal integrated clerkship graduates

This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time.

Students' workplace learning in two clerkship models: a multi-site observational study

Medical Education 2012: 46:613–624

Learners, performers, caregivers, and team players: Descriptions of the ideal medical student in longitudinal integrated and block clerkships

Abstract Background: Hidden curriculum literature suggests that different learning environments and curricular designs reinforce disparate values and behaviors. Aim: This study explores potential differences in learning environments afforded by two clerkship models through perceptions of the ideal student. Methods: In this qualitative study, research assistants interviewed 48 third-year students and 26 clinical supervisors from three US medical schools. Students and supervisors participated in longitudinal integrated clerkships (LICs) or block clerkships. Students and supervisors described the ideal student in their clerkship. Using phenomenographic techniques, authors identified five ideal student profiles and coded students’ and supervisors’ descriptions for alignment with one or more profiles. Results: Most students in both models described an ideal student who matched a learner profile (proactive and self-directed). More LIC students described an ideal student who fit a caregiver profile (engaging with and advocating for patients) and more block students described performer (appearing knowledgeable and competent) and team-player (working well with others) profiles. Supervisors’ descriptions paralleled students’ descriptions but with less emphasis on caregiving. Conclusions: Ideal student descriptions in LIC and block models may reflect different learning experiences and values emphasized in each model. These findings suggest implications for students’ construction of professional identities that warrant further exploration.

The Harvard Medical School Cambridge Integrated Clerkship: challenges of longitudinal integrated training

R ecently, in the world of medical education, much attention has been given to longitudinal integrated models of clinical training. Such models are designed to remedy the discontinuity inherent in traditional specialty-specific, randomlysequenced block rotations. These new programs feature continuities of patient care, curriculum and supervision. Students learn the cross-disciplinary skills of doctoring by engaging in close, longitudinal relationships with patients and teachers.

Teaching Medical Students About Cancer Impact Through a Longitudinal Surgical Experience: A Case Study

Background: We designed and execute a longitudinal curriculum that provides a comprehensive understanding of cancer illness and its impact upon the patient. Summary: The Harvard Medical School–Cambridge Integrated Clerkship is a redesign of the 3rd year where the traditional rotations are replaced by a single integrated year-long experience. Students are required to follow a patient with newly diagnosed gastrointestinal cancer and breast cancer, across all venues and disciplines. Twenty-nine of 34 students responded to a survey. On average patients were followed for 7 months, through 12 encounters across 4 different specialties. Students responded that this experience facilitated their understanding of cancer in a way not feasible in a traditional clerkship model. Conclusions: Medical students perceive that this longitudinal model of cancer education improves integration of the surgical, medical, scientific, emotional, and social issues. Traditional “block rotation” students and even residents are rarely afforded such an educational opportunity.